INDEX

1) Introduction to functional rehabilitation

2) Fundamental anatomical movements

3) Reference positions

4) Posture analysis and correction

5) Orthopedic conditions

6) Mobilization techniques

7) Reference (s)

8) Annexure (s)
Introduction

There are many different ways to exercise and many different ideas about
rehabilitation. It is important to tailor our rehabilitation programs specifically
to your needs.

That means we will often start by creating exercises that will help your
clients with the activities you are struggling with on a day-to- day basis.

Functional exercises are based on improving how you perform

normal activities throughout your day, such as sitting, getting up
from sitting, bending, walking.

The aim is to make these movements easier and pain free, and to use
them to increase your stamina during each day so that you can then
progress into exercises that increase your activity levels or are specific to
your sporting requirements.

As your exercise program progresses you may be asked to increase the

difficulty of each exercise and the number of repetitions in order to improve
your functional capacity, that is to improve your ability to cope with the
demands you wish to put onto your body each day.

Note:

Strength: Can be defined as the application of high force against a heavy

resistance.

Conditioning: A process of physical modification by which a patient

comes to associate a desired behavior with a previously unrelated physical
activity.
Coordination: Harmonious functioning of muscles or groups of muscles in
the execution of movements.

Functional Training: involves more than simply increasing the force-

producing capability of a muscle of group of muscles. Rather, it requires
physical modification to enhance the coordinated working relationship
between the nervous and muscular systems.

Functional Rehabilitation involves performing controlled movements in an

area of dysfunction, in such a manner that the improvements in strength,
conditioning and coordination directly improve the performance of
movements so that an individuals activities of daily living are easier to
perform.
Fundamental Anatomical movements

ABDUCTION: Movement away from the midline of the body

ADDUCTION: Movement towards the midline of the body

ELEVATION: Moving to a superior position at the scapula

DEPRESSION: Moving to an inferior position at the scapula

INVERSION: Lifting the medial border of the foot (insole)

EVERSION: Lifting the lateral border of the foot

FLEXION: Decreasing the angle between two bones

EXTENSION: Increasing the angle between two bones

DORSIFLEXION: Moving the top of the foot towards the shin at the ankle

joint
PLANTARFLEXION: Moving the top of the foot away from the shin at the
ankle

ROTATION: Internal or external turning at the vertical axis of a bone

PRONATION: rotating the hand and wrist medially from the elbow

SUPINATION: Rotating the hand and wrist laterally from the elbow

HORIZONTAL ADDUCTION: From a 90 Degree abduction arm position,

the humerus is fixed towards the midline of the body in the transverse
plane

HORIZONTAL ABDUCTION: From a 90 Degree abduction arm position,

the humerus is extended away from the midline of the body in the
transverse plane

CIRCUMDUCTION: Combination of flexion, abduction, extension and

adduction in a sequence
Reference Positions

Anatomical Position of Body

Anterior - front

Posterior - rear

Lateral- outwards

Medial - inwards

Superior - upper

Inferior - lower

Proximal - close to trunk

Distal - away from trunk

Anterosuperior - front upper

Anteroinferior - front lower

Anteroposterior - front and back

Anteromedial - front inner

Anterolateral- front, outwards

Posterosuperior - rear upper

Posteroinferior - rear lower

Posteromedial - rear inner

Posterolateral - rear, outer

Caudal- inferior (in relation to)

Cephalic - upper, above

Deep - below surface

Infra - inferior

Supra - superior

Ipsilateral-on same side

Prone-lying down on stomach

Supine-lying on back

Superficial-near surface

Ventral-related to abdomen

Volar-related to palm or foot

Dorsal-related to back

Contralateral-relating to opposite side

Midline-imaginary line that travels thru center of body.

Posture

While clients often express a desire to lose weight, tone or shape their
bodies, or improve their overall fitness levels, one primary object of their
training programs should be to enhance the ability of the clients activities
of daily living. Posture is the position of different parts of the body at
rest or during movement.

To conduct a posture evaluation, the specialist in exercise therapy utilizes

a posture screen or plumb line in conjunction with observations. A plum
line is a thick piece of rope suspended from the ceiling with a weighted end
that does not reach the floor.

Good posture (Diagram-Anteriar and posterior)

Common faulty postures: Characteristics and impairments

The head, neck, thorax, lumbar spine, and pelvis are all related and
deviations in one region affect the other areas. Muscular imbalance and
postural deviations can be attributed to many factors that are both
correctible and non correctible.
Correctible factors

- Muscular overload

- Habitually poor posture

- Side dominance

- Lack of joint stability

- Lack of joint mobility

- Imbalanced strength training

Non-correctible factors

- Congenital conditions (scoliosis)

- Some pathology (rheumatoid arthritis)

- Structural deviations (tibial torsion, femoral ante version)

- Certain types of trauma

Anterior/posterior view

Have the patient stand so that a plumb line is at a point midway between
the medial malleoli

Note:

1. Head twist (Torticollis)/Head tilt

Check the evenness of the earlobes and indicate left or right ear lobe

2. Shoulder level

Note evenness of acromian process and indicate left or right drop

3. Linea alba

Indicate a left or right shift

4. Anterior superior iliac spines

Note evenness and indicate left or right drop

5. Leg alignment

Beginning at the center of the knee, draw a line perpendicular to the floor.

A. Internal/external rotation at the hip. The knee and the foot both point
outward or inward

B. Internal tibial torsion. The patella faces inward when the feet are
together, pointing forward

C. Genu valgum(knock knees). Note the space between the medial

malleoli when the knees are touching

D. Genu varum (bowlegs). Note the space between the femoral condyles
when the feet are together.

E. Pronation. The big toe falls laterally to the plumb line drawn from the
centre of the knee

Lateral view

Draw a plumb line beginning with a point 1 inch anterior to the center of the
lateral malleolus and precede upward, perpendicular to the floor. In ideal
posture, the plumb line should pass through the following fixed
checkpoints; centre of the knee, centre of the hip, centre of the shoulder,
and the earlobe. Postural abnormalities are based on the deviation from
this line.

A. Body lean - Indicate whether forward or backward

B. Head - Considered forward if the earlobe is in front of the acromion

process

C. Shoulders considered forward if the acromian process is in front of the

plumb line

D. Kyphosis - Excessive flexion in the thoracic spine

E. Lordosis - Excessive hyperextension in the lumbar spine

F. Ptosis - Protrusion of the abdomen. Abdominals should not extend

beyond a line drawn down from the sternum

G. Genu Recurvatum (Hyperextended knees)

Patella falls behind the plumb line

H. Scoliosis

This is the abnormal lateral curvature of the vertebral column. Depending

on etiology there may be one curve, or primary and secondary
compensatory curves. Scoliosis screening is usually performed on children
in elementary and secondary grades, since treatment is very difficult after
bone growth is complete. However, older participants experiencing low
back pain may benefit from this type of screening to determine the nature
of their pain Procedures for spinal screening
1. Ask if there is history of Scoliosis in the family

2. Look at the participants back while he/she is standing. Ask yourself

Are the earlobes level?

Are the shoulders the same level?

Are the inferior borders of the scapula the same level?

Are the arms the same distance from the body?

Are the trunk contours the same on both sides of the body?

Are the hips level?

Are the popliteal creases level?

3. The participant bends forward about 90 degree with hands together, feet
together, and head down as if diving into a pool.

View the participant from the back. Ask yourself:

Is one side of the thoracic or lumbar spine higher than the other?

4. The participant bends forward as above, but view the participant from
the front. Ask yourself:

Is one side of the thoracic or lumbar spine higher than the other?

5. Take a quick look at the side view of the participant as a check for
kyphosis. Ask yourself: is the curve even or does it peak?

Posture exercises
1 .Postural deviation, Forward head

Neck flattener press back of the neck firmly to the floor and hold for 5
seconds. This strengthens the neck flexors and extensors.

Revolving neck flattener press back of the neck firmly to the floor.
Slowly turn the head from side to side. This strengthens the neck flexors,
extensors, rotators

2. Postural deviation; Forward shoulder/Kyphosis

Shoulder retraction clasp hands over lower back and attempt to draw
elbows together.

Wall lean face corner of room, one hand on either wall at shoulder
height. Incline body toward the corner, bending elbows. This stretches the
anterior chest muscles.

Prone lift arms extended sideward Pinch shoulder blades together.

Raise arms slightly from the mat. Raise head from the mat and hold for 5
seconds.

Towel stretch Raise the towel overhead. Hold for 10 seconds. Lower the
towel obliquely across the back and hold for 10 seconds. This strengthens
the muscles that retract the shoulders and adduct the scapula. This also
strengthens the external rotators of the shoulders. This stretches the
anterior chest muscles.

Prone flysSlowly raise the dumbbells out to side and above level of the
body. Arms can be slightly bent. This strengthens the muscles that retract
the shoulders and adduct the scapula.
Shoulder flexion with pulleyskeeping arms straight, slowly lift pulleys
overhead. Do not arch lower back. This strengthens the upper back
extensors

3. Postural deviation of the lower extremities

Heel cord stretch hands on the wall shoulder high and shoulder width
apart, elbows slightly bent. Bend arms until chest nearly touches the wall.
Keep body in straight line, keep heels on the floor.

Progression: from starting position, move backward about an inch at a time

keeping heels on the floor.

This helps to stretch the heel cord and back of leg. This is beneficial in pes
planus, pronation

Ankle stretchraise on toes as high as possible. Lower the bodies to

stretch the heel cord as heels are slowly below the level of the support. Be
sure weight is one the outer margin of feet at all times and stand tall
throughout the exercise. Hold this for 30 seconds.

This helps to stretch the anterior tibial and calf muscles. This is beneficial
in pes planus and pronation, fractures of the ankles, post-opereative repair.

Foot supinator cross the leg so the ankle of right foot rests across the
left knee, keeping the foot at right angle to the right leg and turning the sole
of the foot upward. Place the left palm on the medial border of the right
foot. Attempt to push the right foot downward. Resist and hold the foot in
supination. Hold for 10 seconds.

This strengthens the invertors and supinator of the foot. It is benefial in pes
planus (flat foot) and pronation.
Orthopedic conditions

When there is an injury to the human body, a variety of structures can be

damaged, including bone, cartilage, ligaments, and muscle.

Additionally it is common for damage to the skin, nerves, blood vessels,

and viscera to occur. Thus having a basic understanding of common
musculoskeletal injuries will help a personal trainer provide safe and
effective exercise programming and make appropriate referrals to the
healthcare system.

Types of tissue and common tissue injuries:

Muscle strains and sprains

Muscle strains are injuries in which the muscle works beyond its capacity,
resulting in microscopic tear of the muscle fibres.

In mild strains the client may report tightness or tension. In more severe
cases, the client may report a sudden tear or pop that leads to immediate
pain and weakness in the muscle.

Grading system for muscle strains

Grade 1- This is a mild strain; a few muscle fibers are stretched or torn.
The injured muscle is tender but has normal strength

Grade 2- This is a moderate strain; a large number of fibres are injured

and there is more severe muscle pain and tenderness. Mild swelling is
present, with a noticeable loss of strength and possible bruising.
Grade 3 - This is a complete tear. Sometimes a tear or a pop sensation is
felt as the muscle tears. Grade 3 strains result in complete loss of muscle
function, severe pain, swelling, tenderness and discoloration.

Risk Factors

Poor flexibility, poor posture, muscle imbalance, improper warm up and

training errors.

Ligament Sprains

Ligament sprains foten but not always occur with trauma such as fall or
during sports.

The most common joints for sprains are the ankle, knee, thumb or finger
and shoulder.

If a sprain occurs the client may report a popping sound followed by

immediate pain, swelling, instability, decreased ROM (Range of motion)
and a loss of function.

Anterior Cruciate Ligament Injuries (ACL)

Anterior cruciate ligament sprains are common in contact sports and those
involving a sudden change of direction. Often an ACL injury will occur in
combination with injury to other structures in the knee joint and require
immediate first aid.

Symptoms

Symptoms include sudden pain in the knee joint at the time of injury,
sometimes with an audible pop or crack. The athlete may have a feeling of
instability and rapid swelling may occur from bleeding within the joint,
which will feel warm to touch.

ACL Injuries are the most common sports related injuries of the knee. The
role of ACL is to prevent anterior glide of the tibia away from the femur. The
mechanism of injury often involves deceleration of the body combined with
a maneuver of twisting, pivoting or sidestepping

For exercises See Annexure - ACL (At the back of the manual)

Grading system for ligament injuries

Grade 1-Minimal tenderness, minimal swelling, weight bearing as

tolerated, full ROM, stretching and strengthening exercises as tolerated.

Grade 2- Moderate tenderness, moderate swelling, moderate ROM,

complete tears of some but not all collagen fibres, immobilization with a
splint ROM and stretching and strengthening exercises.

Grade 3- Significant swelling, significant tenderness, complete rupture of

ligament, immobilization, and possible surgical reconstruction

Arthritis

Arthritis is a chronic condition that is characterized by inflammation and

associated joint pain. Prevalence is higher in women, obese and
overweight individuals and physically inactive people.

The most common types of arthritis are osteoarthritis and rheumatoid

arthritis

1. Osteoarthritis - A degenerative disease that leads to deterioration of

cartilage and development of bone growth at the edges of the joints. It is
commonly referred to as the wear and tear arthritis as it is frequently seen
in the weight bearing joints of the body

2. Rheumatoid Arthritis - It is a chronic and systemic inflammatory

disease. It is classified as an autoimmune disease and the exact cause is
unknown. It is characterized by joint pain, swelling and stiffness and in
more severe cases contractures. It is a systematic autoimmune condition.
RA (Rheumatoid arthritis) begins before the age of 40.

Symptoms

Fatigue tenderness on or around the joints, inflammation, pain and

swelling, stiffness

Many people with RA lose their appetite; sometimes fever as well as

development of rheumatoid nodules under the skin

Clinical differences between Rheumatoid arthritis and Osteoarthritis

RA OA
Occurs at any age; onset is more Occurs after the age of 45 years
common in the age of young and
middle aged people
Systemic illness disorder Local joint disorder
Many joints involved, symmetrical Involvement is one joint,
involvement asymmetrical involvement

Exercise and Arthritis

1. Increases strength and flexibility around joints

2. Helps maintain or increase bone strength

3. Provides nourishment and lubrication to the joints

4. Prevents disuse syndrome

5. Provides a feeling of control and self worth

How often should the exercises be performed?

On a daily basis

When there is the least amount of stiffness and pain

When the individual is least tired
When the individual receives the maximum benefit from medications
during the day

Important Note: An extended period of warm up and cool down period is

required

Proper posture has to be maintained

Encourage full ROM (Range of motion)

Preparation for exercise by warming up the body using massage, heating

pad, warm shower or gentle rhythmic movements

Con traindications

Avoid positions of extreme weight bearing flexion or hyperextension

Avoid jarring movements or quick directional changes
Never exercise a hot joint
Never allow client to mask pain with medication

Exercise guidelines
Proper body weight is of paramount importance. Obesity accelerates the
damage to diseased weight bearing joints thus a program of low impact
aerobic activities (to avoid overstressing the joints) is important

Activities such as walking on soft surfaces, elliptical training, cycling, owing

and aquatic exercises are excellent choices.

Clients with hip, knee arthritis should avoid jarring exercises such as
jogging, running, and stair climbing while those with elbow symptoms
should avoid rowing.

Personal trainer should emphasize proper body alignment and proper

exercise technique at all times.

Strength training should emphasize on increasing the number of

repetitions rather than increasing the weight being lifted.

Individuals with rheumatoid arthritis should not exercise during periods of

inflammation and regular rest periods should be stressed during exercise
sessions.

Personal trainers should modify the intensity and duration depending on

the client's response.

Do exercises that improve functional fitness e.g. chair squat.

Examples

1.half squats

2.straight leg lifts

3.isometric knee contraction

4.1unges

5. cycling

6.prone knee extension

7.calf stretches

8.hamstring stretches

9.gluteal stretches

Fibromyalgia

Fibromyalgia is characterized by long lasting wide spread pain and

tenderness at specific points on the body. Many times it is accompanied by
other problems such as irritable bowel syndrome, headache and sleep
difficulties

Chronic pain syndromes, such as fibromyalgia present some of the most

challenging and frustrating dilemmas

Common symptoms

Aches and pains similar to flue like exhaustion Multiple tender points

Stiffness

Decreased exercise endurance

Fatigue

Muscle spasms

Pares thesis (Partial paralysis)

Other symptoms commonly described include excessive fatigue, disruptive
sleep patterns, bowel and bladder irritability, anxiety, depression, cognitive
difficulties, temperomandibular joint syndrome. sensitivity to loud noises
and allergic symptoms such as nasal congestion and rhinitis.

Exercise programs for FMS (Fibromya/gia syndrome)

Fibromyalgia clients should be made to exercise on a regular basis

Gentle stretching should become a part of the daily routine

Warm water exercises are especially beneficial for individuals with

fibromyalgia along with low impact aerobics

Low to moderate intensity exercises are recommended with a goal of

developing consistent exercise patterns rather than intense workouts

Intensity or duration should be reduced during periods of flare up and

increased fatigue or pain resulting from previous activity

Chronic Fatigue Syndrome (CFS)

CFS is a debilitating and complex illness that is characterized by profound

incapacitating fatigue lasting at least 6 months

The female to male ratio of CFS is 4: 1

Characteristic symptoms

Unrefreshing sleep

Muscle and joint pain without inflammation and redness

Headaches

Tender cervical or axillary lymph nodes

Recurrent sore throat

Extreme exhaustion lasting more than 24 hours following physical or

mental exercise

Additional symptoms such as abdominal pain, bloating, and chest pain,

chronic cough, diarrhea, dizziness, nausea, chills and nights sweats,
psychological problems and visual disturbances.

Recovery rates from CFS may be rare, with an average of only 5 to 10%
sustaining total remission.

Some typical activities

Water based activities

Miled aerobics

Gentle weight training

Pilates and/or yoga

Low back problems

There are many ideas about what causes LBP (Low back problems) but no
typical explanation can be applied to everyone. Typical causes are trauma,
sports injury, lifting, bending or reaching, sudden jolt in the car, certain
disorders such as arthritis and aging

Low back pain has many sources:

There is the person who has just hurt their back acutely from an
incorrect lift or a sporting injury. Often the pain is muscular or due to
a facet joint strain
There is the person who has had a disc or nerve root injury and is
struggling to sit or get their pants on, and can not get their muscles
to hold them up
Sciatic nerve and pudendal nerve irritation can cause buttock and
leg pain that limits walking and activity
There is the person who has had grumbling back pain for many
years. Over time they realize their back pain is making them do less
at home, work, and play. They notice they have less strength but any
time they try to exercise their back pain gets worse.
There is the person who gets back ache from sitting and standing
too long, and has pain every night when they go to bed or get out of
bed in the morning
There is the person who feels there back is weak, and knows their
posture is poor but does not know how to improve it

Symptoms vary, ranging from muscle ache to shooting or stabbing pain.

Chronic back pain is generally defined as pain that persists for more than
three months. In some people the spine becomes overly strained or
compressed, resulting in a disc rupture or outward bulge that places
pressure on one of the more than 50 nerve roots rooted to the spinal cord.
Other causes include conditions such as spinal stenosis, osteoporosis and
associated fractures, spinal degeneration, and spinal irregularities (Such
as scoliosis, kyphosis and lordosis)

Exercise guidelines

A sound exercise program is designed to provide support and strength to

the spine.

Trunk stabilized is essential for preventing injury to the lower back while
performing any movement or daily activity. Always begin these exercises
slowly and carefully like by holding for a count of five allowing the muscles
to loosen up gradually.

Important tips to remember

Find out if client has flexion bias or extension bias.

Stand with feet evenly distributed over left and right feet
Stand with weight evenly distributed over front and back of feet.
Stand with head and chin parallel to the floor.
Stand with slightly bent knees.
Stand with firm abdominal muscle support
If a client experiences leg pain and backache, along with any or all
of these (high fever, loss of bowel and bladder function, rapid weight
loss, back pain lasting more than 3 days, numbness in pelvis and
extreme weakness in the leg) see a physician immediately.
Common ways to reduce the low back pain

Have knees higher than hips when sitting

Move the drivers seat close to the steering wheel.
Tighten the abdominal muscles when you are about to lift anything.
Never bend at the waist and lift; rather bend at hip hinge joint.
Do back exercises daily
Never twist forcefully
Push, do not pull
Strengthen core muscles of torso.

Exercises for lower back

Press back extensions

Bird dog

Knee to chest

Pelvic tilts

Bridging
Other pilates mat level exercises (check with us for our next pilates
program)
Osteoporosis

Osteoporosis is characterized by loss of normal bone density mass, which

leads to increased porosity of the bone which in turn makes the bone more
vulnerable to fractures

Leading causes

Family history, inadequate vitamin D and calcium, and low levels of

estrogen following menopause. It is more common in women than men.
Women who smoke or are thin and have fair complexions are more
susceptible

Things to be avoided in a client with osteoporosis

Avoid all situations that could lead to a fall

Get rid of throw rugs and light up dark hallways
Quit smoking and drinking an excessive amount of soft drinks
Avoid caffeine
Avoid quick twisting movements
Avoid poor posture when sitting standing and lifting
Be careful of drugs that cause you to get dizzy
Check if calcium supplements helpful
Ask if hormone replacement therapy useful
Recommend the client for a bone scan

Sample exercise recommendations for clients with osteoporosis

 Start a slow walking program. Try stationary bicycling or using a
cane while walking
Strengthen the muscles of the upper back and stretch the chest
muscles
A recent study has shown that by doing strength and flexibility
exercises the effects of dowagers hump is diminished.
Swimming and water exercises are good for cardio vascular
exercise but the verdict is still out to whether these really increase
bone density
Do not bend over or lift anything. This places undue stress on the
bones of the lower back. Instead bend the knees while lifting.
Resistance training is also an important component in the prevention
of osteoporosis depending on the clients physical condition and
medical profile, higher intensity strength training exercises may
derive the most benefit to bone. Bone loading stimulates the bone
deposition which helps in gaining bone mass and strength.
Shoulder problems

Shoulder problems may be the result of many different causes such as

osteoarthritis, trauma, bursitis and tendinitis

Many times the corrective exercises are the same no matter what the
cause

Shoulder strain/sprain

Strains most often involve a tendon, while sprains involve ligament. These
injuries can eventually lead to rotator cuff injuries if not managed correctly.

This occurs when the soft tissue structures (bursa, rotator cuff tendons) get
abnormally stretched or compressed. Strains usually involve a tendon

Impingement is particularly common in young individuals who participate in

overhead activities such as tennis, baseball and swimming.

Signs and symptoms

Local pain, swelling and tenderness in the shoulder that causes pain and
stiffness with movement

Exercise program

Educate clients on avoiding aggravating activities and improving

posture and body positioning
Regain strength and flexibility of the shoulder complex
Strengthen the scapular stabilizers (rhomboids, middle trapezius,
serratus anterior) and rotator cuff muscles which will help restore
scapulohumeral motion
 Stretch the major muscle groups around the shoulder to restore
proper muscle length to these muscles
Overhead activities often need to be modified
The client should only move through a portion of the ROM

Rotator cuff injuries

The shoulder joint is a ball and socket joint like the hip joint except that the
hip joint is a deeper joint and thereby provides a lot more support although
with a limited mobility

The shoulder joint is a flatter and smaller joint. While this design affords us
a great deal of movement, we pay the price for it with a joint that is at the
risk for misuse and abuse

Some experts believe that when you move your arm as many as 26
muscles are engaged in the movement. Go to any gym and you will see
men and women doing all kinds of overhead presses to build up the show
muscles. However they often neglect the very important SITS muscles

Researchers suggest that the rotator cuff muscles display the greatest
electrical activity during the eccentric phase of the follow through of major
arm movements

Causes

Age: the risk for a rotator cuff injury increases with age. Normal wear
and tear, an increase in the calcium deposits within the joint and
bone spurs can irritate the rotator cuff.
Trauma: an injury to the shoulder joint whether it is a fall or any kind
of trauma is another source of problem for the shoulder joint.
 Overhead activities

Signs and symptoms

If an acute injury happens the client will hear a tearing sensation followed
by immediate pain and loss of movement. The client will have typically
have trouble lifting his or her arm above the head. Chronic tears show a
gradual worsening with increased pain at night or after increased activity.
Reaching overhead or behind the back is painful

Corrective exercises

The V soda can lift

Starting position: Stand erect with arms alongside the body.

Movement: Then, as if holding a soda can with the thumbs facing down,
slowly lift the arms outwards as if pouring soda on the floor. Raise the arms
to the height of the shoulders with hands slightly behind the back

Internal rotator

Starting position: Stand erect with the elbow bent, the elbow and upper
arms against the body, and the hand straight ahead

Movement: Then slowly allow the hand to move toward the abdomen. As
the client improves, resistance can be added

External rotator

Starting position: Have the client stand as in the internal rotator exercise
just described above
Movement: Assume the same basic position, except this time slowly allow
the hand to move outward and then return to the starting position

Forward can lift

Starting position: Standing upright with optimal posture, use both hands to
hold on to a towel or a broom handle. (The towel should be in a horizontal
position across the front of the body; the hands should be placed a
comfortable distance apart with the palms up)

Movement: Slowly lift the arms as high as possible without arching the
back or causing pain. Then return to starting position

Rear can lift

Starting position: Standing erect, hold on to a towel or broom handle

behind the buttocks

Movement: Straighten both arms and very slowly lift them as far away from
the buttocks as is possible to do comfortably

Choker stretch

Starting position: Stand erect with the arms out at 90-degree angle to the
body

Movement: Gently pull the arm across the front of the body until a pleasant
stretch is felt in the back of the arm and in shoulder muscles
Hip problems

Greater trochanter bursitis

This is characterized by painful inflammation of the greater trochanter

bursa between the greater trochanter of the femur and the gluteus medius
tendon\proximallT band complex

Inflammation of the bursa may be due to an acute incident or repetitive

trauma to the area. Acute incidents may include trauma from falls, contact
sports and other sources of impact. Repetitive trauma may be due to
excessive friction from prolonged running, cycling or even kickboxing

Signs and symptoms

The client may walk with a limp (TRENDELENBURG GAIT) due to pain
and weakness. This often results in decreased muscle length, myofascial
tightness and decreased muscular strength

Exercise programming

The exercise programming should include

Stretching of the illiotibial band complex, hamstrings and quadriceps

should be the focus to ensure proper lower extremity mobility.
Strengthening the gluteus and deeper hip rotator muscles is
important to maintain the adequate strength
Proper gait techniques in walking and running should be a priority
These clients should avoid side lying positions they compress the
lateral hip. Higher loading activity such as squats or lunges may not
be immediately tolerated
Illiotibial band syndrome

ITBS is a repetitive overuse condition that occurs when the distal portion of
the illiotibial band rubs against the lateral femoral condyle

Risk factors

Overtraining
Improper footwear or equipment use
Changes in running surface
Muscle imbalance
Structural abnormalities
Failure to stretch correctly

Signs and symptoms

A gradual onset of tightness, burning or pain at the lateral aspect of

the knee during activity
The pain may be localized but generally radiates to the outside of
the thigh
The pain may appear as a sharp stabbing pain along the lower
outside of the knee
Snapping, popping, or pain may be felt at the lateral knee when it is
flexed and extended
Exercise programming

The client may present with weakness in the hip abductors, illiotibial band
shortening, and tenderness throughout the illiotibial band complex

The exercise program should focus on regaining flexibility and strength at

the hip and lateral thigh.

Clients with ITBS may not tolerate higher loading activities such as lunges
or squats. Lunges and squats limited to 45 degrees of knee flexion can be
introduced with a progression to 90 degrees and beyond if tolerated

Exercise recommendations

Because a tight musculature is often implicated in hip problems, a

gentle stretching and flexibility program would be prudent
Avoid high impact activities
A well designed water exercise program would be useful
Avoid full flexion i.e. deep squats or pulling knee into the chest
Avoid crossing legs when exercising or moving either leg past
midline
Knee problems

Patellofemoral pain syndrome

This is often called "anterior knee pain "or "runners knee" and is often
confused with chondromalacia

Causes

Overuse-PFPS can occur when repetitive loading activities cause

abnormal stress to the knee leading to pain and dysfunction. The
excessive loading exceeds the body's physiological balance, which leads
to tissue trauma, injury and pain

Biomechanical causes - This can alter tracking of the patella and/or

increase patel/ofemoral joint stress. Pes plan us has been associated with
PFP because it alters the alignment of the knee. Loss of the medial arch
flattens the foot, causing a temporary internal rotation of the tibia or femur
that alters the dynamics of the patel/ofemoral joint

Conversely pescavus provides less cushioning than the normal foot, which
leads to excessive stress on the patellofemoral joint

Muscle dysfunction-muscle tightness and length deficits have been

associated with PFPS

Signs and symptoms

Commonly reported symptoms include pain with running, ascending or

descending stairs, squatting, or prolonged sitting
The client will typically describe a gradual achy pain that occurs behind or
underneath the patella

Clients may also report knee stiffness, giving way, clicking or a popping
sensation during movement

Exercise programming

The personal trainer must remember that restoring complete flexibility and
strength is the key with PFPS

Addressing tightness in the ITband complex through stretching and

myofascial release can have a major impact on the dynamics of the PFPS
joint

Stretching of the hamstrings and calves will also help in restoring the
muscle length balance across the knee joint

Exercise should focus on restoring proper strength throughout the hip,

knee and ankle

Exercises for the hip and ankle complex should be included due to their
effects on the knee joint

Closed chain exercises such as squats and lunges may be beneficial.

Caution should be taken with open chain exercises due to the abnormal
stress it can impose on the patella

Resistance band exercises for the ankle are commonly used to build
strength
Indicated exercises

Quad setting

All squats

Halfway down chair squats

Closed knee extension

Terminal leg extension

Forward lunges with knee over foot

Leg curls
Ankle Sprains

Ankle sprains are very common in the athletic population. These are most
common in basketball, volleyball, soccer and ice-skating

Types of ankle sprains

Lateral or inversion ankle sprain is the most common type. The mechanism
of injury is inversion with a plantarflexed foot

Exercise programming

The aim of ankle rehabilitation exercises is to restore full pain free

range of motion to the joint, strengthen the surrounding muscles,
improve proprioception and prepare the athlete for normal training
and competition

Restoring proper proprioception

Flexibility
strength
Balance

Stretching of the gastronemius and soleus muscles may be beneficial if the

client has tightness in these muscles and decreased length in the Achilles
tendon after immobilization.

Targeting the peroneal muscle e group for inversion ankle sprains is

important to prevent re-injury
Indicated exercises

The exercises below from part of an ankle rehabilitation program and

consist of mobility exercises, strengthening exercises and functional
exercises.

Heel cord stretch

Seated gas pedal

Seated ankle circles

Seated foot inward/outward

Elastic hard gas pedal

Elastic hard foot inward/outward

SPECIAL POPULATION

INDEX

INTRODUCTION

CARDIOVASCULAR DISEASES

HYPERTENSION

DIABETES

ASTHMA

LOW BACK PAIN

ARTHRITIS

FIBROMYALGIA

OSTEOPOROSIS

ANXIETY

EPILEPSY
Personal trainers frequently encounter clients with special needs and
health concerns. CHRONIC DISEASES such as cardiovascular disorders,
cancer, diabetes and the metabolic syndrome are the leading cause of
death and disability.

Because of this rapid rise in the chronic disease, it is important for the
personal trainer to identify and address the health conditions before
working with a client. Once a clients medical and/or health conditions have
been identified, the personal trainer must obtain physician approval before
proceeding with exercise program.

The SOAP note is (an acronym for subjective,objective,assessment and

plan)commonly used by healthcare providers to document the patient
progress.

SUBJECTIVE-observations that include the clients own status report, a

description of symptoms, challenges

OBJECTIVE-measurements such as vital signs, height, weight, age,

posture, exercise and other test results.

ASSESSMENT-a brief summary of the clients current status.

PLAN-a description of the next steps in the program based on

assessment.

The SOAP note is an elegant and efficient way to communicate both what
the client feels and what the personal trainer observes.
CARDIOVASCULAR DISORDERS

This continues to be the leading cause death in the developed countries

Well established factors include:

Family history

Hypertension

Smoking

Diabetes

Age

Dyslipidemia

Lifestyle

CAD also called as atherosclerotic heart disease is characterized by the

narrowing of the coronary arteries that supply the heart muscle with blood
and oxygen. The narrowing is the inflammatory response within the arterial
walls resulting from an initial injury and the deposition of lipid rich plaque
and calcified cholesterol.

Heart attacks or myocardial infarctions arise from the rupture of vulnerable

plaques and the associated release of thrombotic substances that critically
narrow or completely close the diameter of the artery

ATHEROSCLEROSIS is also the underlying cause of cerebral and

peripheral vascular diseases. Manifestations of atherosclerosis include
angina, heart attack, stroke, and intermittent claudication.
EXERCISE AND CORONARY ARTERY DISEASE

Exercise is also a critical part of the treatment regime for people with CAD.
Since the early 1960s many reports have been established documenting
the benefits of progressive physical activity in reducing the mortality and
the morbidity rate. Today exercise program is an essential component of
the therapeutic regimen for people with CAD.

Most patients who have been released to take part in ACTIVITIES OF

DAILY LIVING will also have been given some basic exercise guidelines. It
is appropriate for the personal trainer to inform prospective clients that
cardiac rehabilitation programs are available.

EXERCISE GUIDELINES

All clients with documented CAD should have a physician supervised

maximal graded exercise test to determine their functional capacity.
Exercise guidelines are based on the status of the client and it is more
appropriate for personal trainers to work with low risk CAD low risk CAD
clients will have stable cardiovascular and physiological responses to
exercise.

Most low risk clients can benefit from the improvement of muscular
strength and endurance that occurs with appropriate resistance training
program.

Clients should be taught proper technique

That includes breathing and moving through a full, pain free ROM.
Begin with low level exercises that use light weight dumbbell and gradually
progress to weight machines. Other potential modes include using
bands/tubing, calisthenics, exercise balls

Clients should perform one set of 10-15 repetitions using eight to ten
exercises that target the major muscle groups twice a week. Heart rates
should not exceed the training targets of RPE of 11-14.

Exercise should not continue if any of the abnormal signs or symptoms is

observed Angina, dyspnea, lightheadedness,Pallor or rapid heart above
established targets.personal trainers should question clients and observe
them for such signs and symptoms before during and immediately
following each exercise session.

HYPERTENSION

This is sometimes referred to as the silent killer .one in three US adults

have high blood pressure defined as having systolic pressure more than
140 mmhg or diastolic pressure more than 90mmhg.

EXERCISE AND HYPERTENSION

Exercise, weight loss, sodium reduction, and reduced fat and alcohol
intake are the important lifestyle therapy components for controlling
hypertension and in some cases augment a clients pharmacological
intervention.

Regularly performing 150 minutes of exercise per week has consistently

shown to reduce SBP by an average of 2 to 6 mmhg.

Exercise also has an acute post exercise effect on both SBP and DBP.
EXERCISE GUIDELINES

Both prehypertensive and hypertensive individuals should participate in 30

minutes and more of regular exercise at least 5 days each week. Aerobic
exercises such as walking, cycling, swimming and using ergo meters are
excellent modes and should be implemented with resistance training.

Circuit training utilizing low to moderate resistance and high repetitions is

an excellent resistance training program.

The personal trainer should ask for a list of current medications and
recommendations from the clients physician when obtaining the exercise
release and guidelines.

The personal trainer should measure the clients pre and post exercise
blood pressure.

Physicians may instruct their hypertensive patients to record their resting

and post exercise blood pressure and the personal trainer should review
their logs.

The exercise session should be discontinued if the SBP or DBP rise to 250
mmhg or 115mmhg respectively.

Yoga and tai chi have been shown to be beneficial for clients with high
blood pressure. Isometric muscle contractions and inverted positions
should be avoided.

DIABETES
This is a group of diseases that are characterized by high levels of blood
glucose resulting from defects in insulin production, insulin action or both.

It causes abnormalities in the metabolism of carbohydrate, protein and fat

and when left untreated or inadequately treated results in a variety of
chronic disorders and premature death.

People with diabetes are at higher risk for developing chronic health
problems, including heart disease, stroke, kidney failure, nerve disorders
and eye problems.

There are 3 main types of diabetes

TYPE 1 DIABETES/INSULIN DEPENDENT DIABETES MELLITUS

This is when the bodys immune system destroys the pancreatic beta cells
that are responsible for producing insulin. This can occur at any age.

People with type 1 diabetes require regular insulin delivered by injections

or a pump to regulate blood glucose levels.

The typical symptoms of type 1 diabetes is

Excessive thirst and hunger

Frequent urination

Weight loss

Blurred vision

Recurrent infections
During periods of insulin deficiency a higher than normal level of glucose
remains in the blood, a result of reduced glucose uptake and storage. a
portion of the excess glucose is excreted in the urine, leading to thirst,
reduced appetite, and weight loss. An elevated level of blood glucose level
is called HYPERGLYCEMIA.

TYPE2 DIABETES is also called NON INSULIN DEPENDENT DIABETES

MELLITUS

.The type 2 diabetes initially presents as insulin resistance, a disorder in

which the cells do not use insulin properly. As the demand for insulin rises
the pancreas gradually loses its ability to produce it.

The combination of insulin resistance and impaired insulin production

leads to frequent states of hyperglycemia. Initial treatment usually includes
weight loss, diet modifications and exercise.

GESTATIONAL DIABETES is a form of glucose intolerance that occurs

during pregnancy. It is more common among obese women, those with a
history of gestational diabetes.

BENEFITS OF EXERCISE

Individuals with type 1 diabetes can reduce their risk for CAD, and improve
insulin receptor sensitivity with a program of regular physical activity.

Individuals with type 2 diabetes through exercise improves lipid profiles

and hypertension fibrinolysis and reduced elevated body weight ,all of
which can be present in type 2 diabetes.

EXERCISE GUIDELINES
Before beginning an exercise program, a client with diabetes should be
screened thoroughly by his or her physician and clearance to exercise
should be obtained. Diabetes self management program focuses on self
behaviors such as healthy eating, physical activity, weight loss, blood
sugar monitoring and recognition of hypoglycemia and hyperglycemia
signs.

Gradual warm up and cool down periods should be a part of every

exercise program. The warm up should consist of five to ten minutes of
light aerobic activity and a period of gentle stretching. Following the activity
session, the cool down should last five to ten minutes and gradually bring
the heart rate down to its pre exercise level.

The blood glucose level needs to be measured before and after each
exercise program. The session should be delayed or postponed if the pre-
exercise blood glucose level is below 100mg/dl. exercise should also be
stopped if the blood glucose level is more than 300mg/dl .

Clients with type 1 should be encouraged to consistently exercise at least

three to five times a week.

It should be combined with a regular pattern of diet and insulin dosage.

People with type 1 diabetes can comfortably exercise at an intensity of

55%to 75% of functional capacity or at an RPE of 11-14.

Individuals with type 2 diabetes may also derive benefit from low to
moderate intensity resistance training consisting of eight to twelve
repetitions of eight to ten different exercises twice a week.
EXERCISE PRECAUTIONS

1. METABOLIC CONTROL BEFORE EXERCISE

AVOID EXERCISE IF FASTING BLOOD GLUCOSE LEVELS ARE MORE

THAN 250 mg/dl

INGESTA DDITIONAL CARBOHYDRATE IF GLUCOSE LEVELS ARE

LESS THAN 100mg/dl.

MONITOR BLOOD GLUCOSE LEVELS BEFORW AND AFTER

EXERCISE.

PROPER HYDRATION IS EXTREMELY IMPORTANT

FOCUS ON CAREFUL FOOT HYGIENE AND PROPER

FOOTEAR.COTTON SOCKS AND CORRECTLY FITTING ATHLETIC
SHOES ARE IMPORTANT.

ASTHMA

THIS is a complete reactive airway disorder. it is a chronic inflammatory

disorder that is characterized by variable and recurring symptoms such as

Shortness of breath
Wheezing

Coughing

Chest rightness

The inflammatory response and subsequent cascade of events are

typically set off by allergens like mold, cigarette smoke, air pollution,
viruses, stress, cold air, exercise. These triggers can activate an
inflammatory response that leads to airway obstruction due to constriction
of smooth muscles around the airways ,swelling of mucosal cells or
increased mucus.

Approximately 80%of people with asthma experience asthma attacks

during or /and after physical activity. Referred to a exercise induced
asthma

EXERCISE AND ASTHMA

When asthma is not a contraindication to exercise, people with asthma

should receive medical clearance from their physicians before starting an
exercise program.

Most people with asthma will bene3fit from regular exercise and can follow
exercise guidelines for the general population.there is also some evidence
that regular exercise can reduce the number and severity of EIA.

Since EIA is brought on by hyperventilation individuals with asthma should

be encouraged to undertake gradual and prolonged warm up and cool
down periods.
EXERCISE GUIDELINES

As with all chronic conditions, a client with asthma should be cleared by his
or her physician prior to beginning an exercise program.

The following general activity guidelines will assist the personal trainer in
developing, monitoring, and progressing an exercise program

1. They should have rescue medication with them all the times

2. The clients should drink plenty of fluids before, during and after the
exercise to prevent dehydration.

3. Clients should avoid asthma triggers during exercise and consider

moving indoors on extremely hot or cold days or when pollen counts
and/or air pollution are high.

4. It is important to keep the initial intensity low and gradually increase it

over time. The peak exercise intensity should be determined by the clients
state of conditioning and asthma severity.

5. Clients with well controlled asthma can typically use the exercise
guidelines for the general population for cardiovascular and strength
training.
Annexure (s)
ANKLE/LOW BACK/SHOULDER- Annexure

Ankle Sprain Exercises

The aim of ankle rehabilitation exercises is to restore full pain free

range of motion to the joint, strengthen the surrounding muscles,
improve propricception and preparation the athlete for normal
training and competition.

The exercises below from part of an ankle rehabilitation program and

consist mobility exercises, strengthening exercises and functional
exercises.

Wobble board mobility

In the early stages of rehabilitation, a wobble board can be used to

increase the range of motion at the ankle. Sit on a chair with the feet
resting on a wobble board or rocker board. Move the feet forwards and
backwards to mobilize the ankle. Avoid sideways or lateral movements
early on or if it is painful as this will stress the injured lateral ankle
ligaments. Later in the rehabilitation phase as pain allows sideways
movements and movements in a circular motion can be performed.

Active planatr flextion and dorsi flexion

This exercise can be done in the early stages and will help prevent the
ankle from seizing up. Simply pull the foot up as for as it will go
(dorsiflexation), hold for a couple of seconds and then point it away from
your (plantar flexion) and hold again. A good method to start with is to
perform 2 sets of 20 reps whilst the ankle is iced and elevated. The
advantage of this exercise is that the damaged ligaments will not be
stressed by sideways movement, the calf and shin muscles maintain
strength and the pumping motion helps to decrease swelling.

Active Inversion and eversion

This exercise will mobilize the ankle sideways and so starts to stress the
damaged ligaments. It should only be started when pain allows and
healing is established. Simply turn the feet so the soles point onwards and
then inwards. The movement should be gradual and within the limits of
pain. Circling the ankle also move the joint into these positions.

Gatronemus stretch

The let to be stretched behind and lean forward, ensuring the heel is kept
in contact with the floor at all times. Hold the stretch for 20 to 30 seconds
and repeat 3 times. This can be repeated several times a day and should
not be painful. A stretch should be felt at the back of the lower leg. If not
then move the back leg further back. A more advanced version of a calf
stretch is to use a step and drop the heel down off it.

Soleus stretch

To stretch the soleus muscle the back leg should be bent. Place the leg to
be stretched behind and lean against a wall keeping the heel down. A
stretch should be felt lower down nearer the ankle at the back of the leg.

Strengthening Exercises

Ankle strengthening exercises can be begin as soon as pain allows. In the

early stages of strengthening any exercises which involve sideways
movements at the ankle you should avoided.
Resisted plantar flexion

Loop a resistance band around the forefoot and hold onto the ends. Point
the foot away slowly allowing it to return to a resting position. Aim for 10-20
reps and 3 sets with a short rest in between. Once this exercise feels easy,
you can increase the strength of the resistance band or progress on to full
calf raise exercises. This exercise can be repeated with a bent knee to
target the soleus muscle lower down the calf area.

Resisted dorsiflexion

Using a rehabilitation band pull the foot and toes up against resistance and
then down again. Aim for 10 to 20 repetitions and 3 sets with a short rest in
between. This is an important strengthening exercise, however it is
important not to over do this one. Remember you will still have to walk on
the ankle after the strengthen session so do not take the ankle to fatigue.
Over time this may also lead to pain in the front of the shin less is
probably more with this exercise.

Isometric eversion and inversion

Once you can do so pain free, try exercises involving eversion and
inversion to help strengthen the muscles which help to control the rolling
action at the ankle. Isometric means there is no movement at the joint
throughout the exercise. A partner or therapist can provide resistance with
the hands, or use a wall or chair leg.

For eversion the athelete should try turning the ankle out against
resistance. For inversion, inwards against resistance. Hold for 5 secoinds,
rest for 3 seconds and repeat initially 3 times and gradually increase upto
to 10 times. As strength improves, this can be extended using a partner or
therapist into a more dynamic action of the therapist moving their hands
against the ankle which much react to prevent it moving.

Resisted eccentric inversion

This exercise is particularly important in helping to